Journal ofmedical ethics 19: 28-31 1993; J Med Ethics: first published as 10.1136/jme.19.1.28 on 1 March 1993. Downloaded from

The medical ethics of the 'Father of Gynaecology', Dr J Marion Sims

Durrenda Ojanuga University ofAlabama, Alabama, USA

Author's abstract find medical treatments for the closure of the fistula. Vesico-vaginalfistula (VVF) was a common ailment Such surgeons as H Van Roonhuyse (1663), among American women in the 19th century. Prior Mettauer (1830), Vidal (1883) experimented with to that time, no successful surgery had been developed fistula repair, and they were all unsuccessful (3). for the cure of this condition until Dr J Marion Sims While some doctors succeeded with isolated cases, perfected a successful surgical technique in 1849. none were able to develop a method of surgery Dr Sims usedfemale slaves as research subjects over a which would consistently yield positive results. four-year period ofexperimentation (1845-1849). This Women with VVF were left to rely on the use of paper discusses the controversy surrounding his use of palliative or other minimal treatment which lessened powerless women and whether his actions were the dribbling of urine, but did not allow the women acceptable during that historical period. to participate fully in everyday life (4). To complicate the situation even more, the copyright. medical specialty ofgynaecology did not exist. . . the Historical background of VVF practice of examining the female organs was Vesico-vaginal fistula (VVF) results in a tear from considered repugnant by doctors who were almost the bladder to the vagina, caused by obstructed all males. In fact, in American medical schools, labour. Women who suffer this disorder are inconti- obstetrics and child delivery were taught by the use nent and continuously leak urine. Vesico-vagina of dummies and often it was not until a doctor was in

fistula has been a problem of women for centuries. practice that he actually delivered a baby. According http://jme.bmj.com/ An embalmed Egyptian woman was discovered with to Wertz and Wertz (1977): a vaginal fistula, and Avicenna, an early Persian doctor, documented cases of vaginal fistulas caused 'Young doctors rarely had any clinical training in by obstructed labour in AD 951 (1). what the theory of birth meant in practice. Many Before the 19th century, European and American arrived at a birth with only lectures and book women suffered from this affliction and often learning to guide them. If they (and the laboring became social outcasts rejected from society. patient) were fortunate, they had an older, Suicides among them were common. Dr J Marion experienced doctor or attending woman to explain on September 30, 2021 by guest. Protected Sims in 1852 described the reaction of one of his what was natural and what was not. Many young patient's to her condition: men were less lucky and were embarrassed, con- fused, and frightened by the appearances of labor 'The accident, per se, is never fatal, but it may well be and birth....'(5). imagined that a lady of keen sensibilities so afflicted, and excluded from all social enjoyment would prefer In the 19th century, American and European death. A case of this kind came under my obser- Victorian values affected access to medical care for vation a few years since, where the lady absolutely gynaecological/obstetrical problems. For example, pined away and died, in consequence of her extreme doctors in the early 19th century performed pelvic mortification on ascertaining that she was hopelessly examinations while looking directly into the eyes of incurable' (2). the women (6). Nudity and exposure of the female body even to the eyes of a doctor was prohibited. Vaginal fistulas were generally unknown to the While statistics are scarce during this period, evi- public at large, but well known doctors attempted to dence suggests that VVF was a serious problem. The records of the Women's Hospital in New York revealed significant numbers of poor immigrant Key words women suffering from this condition. In addition, Human experimentation; women's health; medical medical writings of the period documented cases of history. VVF. Durrenda Ojanuga 29 J Med Ethics: first published as 10.1136/jme.19.1.28 on 1 March 1993. Downloaded from

In the antebellum South, slave-women, due to poor to see if he might cure them. The women were nutrition, lack of prenatal care, and births at an early useless as human chattel since they could neither age were at risk of VVF. Irish immigrant women work in fields nor houses in their condition. escaping poverty in Europe were also afflicted with In the beginning, Sims had refused to treat these the condition. VVF, however, was not restricted to women on the grounds that vesico-vaginal fistula the oppressed and poor women ... even European was incurable. But with his accidental discovery of a Royalty succumbed - the Empress Eugenia of way clearly to see the vagina, he rescinded his prior France had a fistula (4). prognosis and established a small hospital in his backyard for experimental purposes (8). The enslaved women were not asked if they would Dr J Marion Sims agree to such an operation as they were totally with- The doctor who cured Empress Eugenia and devel- out any claims to decision-making about their bodies oped the first successful fistula operation in 1849 or any other aspect of their lives. Sims used a total of was Dr J Marion Sims, an American surgeon. He has seven enslaved women as experimental subjects; been credited with developing the medical specialty permission was obtained from their masters. They of gynaecology and is considered the 'father of were in no way volunteers for Dr Sims's research. gynaecology'. The story of Dr Sims's discovery of a Nevertheless, Dr Sims was so positive that he was successful surgical technique for the cure of VVF is on the verge of making an astounding medical one of coincidence combined with skill. Also, it is a discovery that he invited local doctors to witness his story of pain and suffering, which makes Dr Sims a first operation and what he thought would be a controversial historical figure today. historical event. He performed his first operation on Dr Sims was born in South Carolina in 1813, a slave-woman named Lucy (8). the son of a county sheriff. He received his Lucy was operated on without anaesthetics as medical training at Jefferson Medical College in Sims was unaware of the advances which had been Philadelphia. After graduation, he practised made in this area of medicine. The surgery lasted for

medicine first in Mount Meigs, Alabama, and later an hour and Lucy endured excruciating pain while copyright. moved to Montgomery where he developed an positioned on her hands and knees. She must have interest in surgery (7). It was in Montgomery that he felt extreme humiliation as twelve doctors observed conducted experiments on slave-women which the operation. Unfortunately, the operation failed as resulted in the perfection of a surgical technique for 'two little openings in the line of union, across the the repair of fistula. vagina ... remained although the larger fistula had His interest in working in the area of gynaecology been repaired' (8). was accidental. In fact, in his autobiography he says: Lucy nearly lost her life, due to the experimental http://jme.bmj.com/ use by Sims of a sponge to drain the urine away from 'I never pretended to treat any of the diseases of the bladder, as she became extremely ill with fever women and if any women came to consult me on resulting from blood-poisoning. In recounting the account of any functional derangement of the episode in his autobiography, Sims says, 'I thought uterine system, I immediately replied, this is out of she was going to die ... it took Lucy two or three my line; I do not know anything about it practically, months to recover entirely from the effects of the and I advise you to go to Dr Henry or Dr operation' (8). McWhorter (8).' Despite Lucy's close call with death, Dr Sims on September 30, 2021 by guest. Protected continued with his experiments. He operated on Dr Sims's attitude changed when he was called to Anarcha, another slave-women, next. Her condition attend a woman who had fallen from a horse and was improved considerably after the surgery, but a small in a great deal ofpain around the pelvic area and her fistula remained and she continued to leak urine. back. Believing that the woman had dislocated her With subsequent operations, Dr Sims developed uterus, he placed her in a knees and elbow position new instruments and acquired new knowledge as he and inserted a finger into the vagina, as was standard progressed closer to a cure, yet the amount of procedure in such cases, causing air to rush in and suffering and pain endured by the slave-women extend the vagina to its fullest capacity. He could see subjects as a result of these operations were the interior of the vagina clearly and from this immense. position he believed that he could easily repair a Four years almost to the day after his first fistula. Using a speculum of his own design, which operation, June 21, 1849, Sims successfully repaired had been fashioned from a pewter spoon, Sims Anarcha, by using silver wire as a suture. She had began his experimental surgery which was to last for endured thirteen operations without anaesthesia. four years (1845-1849). He was 27 years old at the Shortly thereafter, all of the slave-women who had time (9). been the subjects of his experiments were cured and Dr Sims used African-American women who were sent home (10). enslaved as his experimental subjects. Slave-women Many white women came to Sims for treatment of with fistulae were brought to Sims by their masters vesico-vaginal fistula after the successful operation 30 The medical ethics ofthe 'Father of Gynaecolog', DrJ Marion Sims J Med Ethics: first published as 10.1136/jme.19.1.28 on 1 March 1993. Downloaded from on Anarcha. However, none of them, due to the perform a surgical operation in which a patient pain, were able to endure a single operation. suffered no pain. James Vernable was a free white As Axelson points out: man. The evidence suggests that Sims's use of slave- 'Sims failed utterly to recognise his patients as women as experimental subjects was by no means autonomous persons and his own personal drive for the order of the day! In fact, after his experiments success cannot be minimised, especially as a balance had continued over a period of years, Sims's reputa- to the enormous amount ofpraise accorded Sims for tion in the community began to deteriorate rapidly. his work and for subsequent applications of the According to Harris (1950), 'all kinds of whispers technique developed in Montgomery and elsewhere' were beginning to circulate around town . . . dark (10). rumours that it was a terrible thing for Sims to be allowed to keep on using human beings as experi- mental animals for his unproved theories' Discussion (13). While the story of J Marion Sims is important in understanding the treatment of vesico-vaginal Conclusion fistula, it also serves as a classic example of the evils By the time of Dr J Marion Sims's death in 1883, he of slavery and the misuse of human subjects for had established a world-wide reputation as a great medical research. surgeon and gynaecologist. Hospitals are named for Kaiser defended Dr Sims's abuse of enslaved him and statutes of Dr Sims can be seen in New African-American women on the grounds that he York and South Carolina. was a man of his time and should not be judged by Yet his fame and fortune were a result ofunethical present-day standards. 'It is easy to derogate Sims by experimentation with powerless Black women. Dr applying 1975 social standards to 1850 decisions Sims, 'the father of gynaecology' was the first doctor and conduct . .. but it is difficult to envision today to perfect a successful technique for the cure of the disparate state of an 1850s woman with total vesico-vaginal fistula, yet despite his accolades, in hiscopyright. urinary incontinence, as it is against this background quest for fame and recognition, he manipulated the that evaluation must be made . .. Sims was a social institution of slavery to perform human product ofhis time ... (1 ). Historical fact however, experimentations, which by any standard is does not support Kaiser's defence of Sims's actions. unacceptable. In fact, significant medical breakthroughs were accomplished without the use of slaves by Southerners during this period. During the 19th Acknowledgement http://jme.bmj.com/ century, slavery was firmly established in the South. The author would like to thank Mary MacLachlan, Slaves worked as field-hands and household Franco-American Center, University of Maine- servants, but they were seldom used as experimental Orono, for her assistance with the historical subjects. research. While the opinions held in this article are For example, Ephraim McDowell (1771-1830) of the responsibility of the author, I would like to thank Danville, Kentucky, was the first person to conduct the following individuals for their comments on the

a successful abdominal operation. McDowell manuscript: Professor David Weiss, Hebrew on September 30, 2021 by guest. Protected removed a 22-pound ovarian tumour from Jane University; Professor Seymour Glick, Ben Gurion Todd Crawford in his own home in 1809 (12). Mrs University; Professor Charles Atherton and Crawford, a white woman, had given her informed Professor Paul Stuart, University of Alabama, consent for the experiment. According to Agatha School of Social Work. Young: Durrenda Ojanuga, MSW PhD, is Associate Professor 'He (McDowell) told Jane precisely what her situa- in the School of Social Work at the University of tion was, explaining to her carefully, so that she Alabama. could not fail to understand .. . . He called the operation an experiment, nothing more, and she knew that it could not be performed swiftly, that References there would be no way of relieving the pain she (1) Hamlin R H J, Nicholson E C. Experiences in the would have to endure and that she was more than treatment of 80 labours which have followed the likely to die while the experiment was in progress. repair of these injuries. Ethiopian medical journal But Jane was brave. She accepted' (12). 1966; IV, Oct: 185-192. (2) Sims J M. On the treatment of vesico-vaginal fistula. American journal of the medical sciences 1852; 23, Jan: Dr Crawford W Long (1815-1878), is another 59-87. example. In Georgia, he removed a tumour from the (3) Russell S C. Vesico-vaginalfistulas and related matters. neck ofJames Vemable in 1842, using sulfuric ether Springfield: Charles S Thomas, 1962. as an anaesthesia (13). He was the first doctor to (4) McGregor, D K. Female disorder and nineteenth Durrenda Ojanuga 31 J Med Ethics: first published as 10.1136/jme.19.1.28 on 1 March 1993. Downloaded from

century medicine: the case of vesico-vaginal fistula. (9) Sparkman R S. Jim Marion Sims - woman's surgeon Caduceus 1987; 3, 1: 1-31. and more. Bulletin of the American College of Surgery (5) Wertz R W, Wertz D W. Lying-in: a history of child- 1975; Mar; 7-11. birth in America. New Horizon: Yale University Press, (10) Axelson D E. Women as victims of medical experi- 1977. mentation: J Marion Sims's surgery on slave-women (6) Leavitt, J W. Brought to bed: childbearing in America, (1845-1850) Sage 1985; 2, 2. 1750-1950. New York: Oxford University Press, (11) Kaiser I H. Reappraisals ofJ Marion Sims. American 1985. journal of obstetrics and gynecology 1978; Dec 15: (7) Ward S B. The father of gynecology. Alabamajournal 878-882. of medical science 1972; 9, Jan: 33-39. (12) Young A. Scalpel. New York: Random House, 1956. (8) Sims J M. The story ofmy life. New York: D Appleton (13) Magner L N. A history ofmedicine. New York: Marcel and Company, 1886. Dakker Inc, 1992. copyright. http://jme.bmj.com/ on September 30, 2021 by guest. Protected